Medicine and Health Sciences Commons^™

Improving Care Of Behavioral Health Patients In A Rural Emergency Department: A Needs Assessment, Margaret Perec

Doctoral Projects

Leadership and staff at a rural Critical Access Hospital (CAH)have identified the need for interventions to address the specific care issue of behavioral health patients presenting to the emergency department (ED). The ED has experienced a higher than expected number of visits, which has presented the department with challenges, especially in finding placements for patients who need inpatient treatment. ED management and staff have reported many patients have experienced long lengths of stay in the ED while waiting for beds.

A needs assessment attempts to identify characteristics of patients who remain in the ED for extended lengths of time, and …

Psychological Determinants Of Physical Activity Across The Life Course: A "Determinants Of Diet And Physical Activity" (Dedipac) Umbrella Systematic Literature Review, Cristina Cortis, Anna Puggina, Caterina Pesce, Katina Aleksovska, Christoph Buck, Con Burns, Greet Cardon, Angela Carlin, Chantal Simon, Donatella Ciarapica, Giancarlo Condello, Tara Coppinger, Sara D’Haese, Marieke De Craemer, Andrea Di Blasio, Sylvia Hansen, Licia Iacoviello, Johann Issartel, Pascal Izzicupo, Lina Jaeschke, Martina Kanning, Aileen Kennedy, Fiona Chun Man Ling, Agnes Luzak, Giorgio Napolitano, Julie Anne Nazare, Grainne O’Donoghue, Camille Perchoux, Tobias Pischon, Angela Polito, Alessandra Sannella, Holger Schulz

Publications

Low levels of physical activity (PA) are reported to contribute to the occurrence of non-communicable diseases over the life course. Although psychological factors have been identified as an important category concerning PA behavior, knowledge on psychological determinants of PA is still inconclusive. Therefore, the aim of this umbrella systematic literature review (SLR) was to summarize and synthesize the scientific evidence on psychological determinants of PA behavior across the life course. A systematic online search was conducted on MEDLINE, ISI Web of Science, Scopus, and SPORTDiscus databases. The search was limited to studies published in English from January 2004 to April …

Alumni Journal - Volume 88, Number 2, Loma Linda University School Of Medicine

Alumni Journal, School of Medicine

Features
12 | A Humble and Gentle Giant: Remembering the man named Small
15 | SDA Guidelines and PAS
18 | The Divine Thread: Dr. Bailie’s life of providential underpinning
22 | To Make Man Flourish: God’s call to decrease physician burnout
26 | APC 2017 in Review

Departments
2 | From the Editor
3 | This and That
4 | From the President
6 | From the Dean
8 | School of Medicine News
10 | The Student Fund
36 | AIMS Report
40 | Book Review
42 | Alumni News
44 | Placement and Classified Ads
45 | …

Time-Restricted Feeding Shifts The Skin Circadian Clock And Alters Uvb-Induced Dna Damage., Hong Wang, Elyse Van Spyk, Qiang Liu, Mikhail Geyfman, Michael L Salmans, Vivek Kumar, Alexander Ihler, Ning Li, Joseph S Takahashi, Bogi Andersen

Faculty Research 2017

The epidermis is a highly regenerative barrier protecting organisms from environmental insults, including UV radiation, the main cause of skin cancer and skin aging. Here, we show that time-restricted feeding (RF) shifts the phase and alters the amplitude of the skin circadian clock and affects the expression of approximately 10% of the skin transcriptome. Furthermore, a large number of skin-expressed genes are acutely regulated by food intake. Although the circadian clock is required for daily rhythms in DNA synthesis in epidermal progenitor cells, RF-induced shifts in clock phase do not alter the phase of DNA synthesis. However, RF alters both …

Metabolic Biomarkers Following A Short And Long Bout Of High-Intensity Functional Training In Recreationally Trained Men, Brian Kliszczewicz, Robert Buresh, Emily E. Bechke, Cassie M. Williamson

Faculty Articles

Glucose regulation is a fundamental process of metabolic function, and is acutely altered by physical activity. High-Intensity Functional Training (HIFT) is a form of exercise performed using combinations of various modalities and durations. It is unknown if the metabolic responses to HIFT are similar to more commonly studied modalities (e.g., cycling and treadmill exercise), or if exercise duration will influence glucose regulation. The purpose of this study was to determine the effect of a Short (< 5-min) and Long (15-min) bout of HIFT on plasma metabolic biomarkers. Ten apparently healthy males (28.11 ± 5.09yrs) participated in this study. Two HIFT sessions (SHORT and LONG) were performed in a crossover fashion. Blood plasma was collected at four time points: PRE, POST, 1HR, and 3HR in order to examine glucose (GLU), insulin (INS), epinephrine (E), and norepinephrine (NE) responses. No trial dependent difference between the SHORT and LONG bouts in GLU (p=0.054), INS (p=0.671), E (p=0.078), and NE (p=0.194). A time effect was observed in both bouts only at POST for GLU (p<0.001), INS (p=0.011), E (p<0.001), and NE (p<0.001). All times returned to baseline values (p>0.05), except for lowered 3HR E (p=0.007). This study demonstrated that both SHORT and LONG bouts of HIFT elicited GLU, INS, E, and NE …

Structure-Based Design Of Hepatitis C Virus Vaccines That Elicit Neutralizing Antibody Responses To A Conserved Epitope, Brian G. Pierce, Elisabeth N. Boucher, Kurt H. Piepenbrink, Monir Ejemal, Chelsea A. Rapp, William D. Thomas Jr, Eric J. Sundberg, Zhiping Weng, Yang Wang

Food for Health: Publications

Despite recent advances in therapeutic options, hepatitis C virus (HCV) remains a severe global disease burden, and a vaccine can substantially reduce its incidence. Due to its extremely high sequence variability, HCV can readily escape the immune response; thus, an effective vaccine must target conserved, functionally important epitopes. Using the structure of a broadly neutralizing antibody in complex with a conserved linear epitope from the HCV E2 envelope glycoprotein (residues 412 to 423; epitope I), we performed structure-based design of immunogens to induce antibody responses to this epitope. This resulted in epitope-based immunogens based on a cyclic defensin protein, as …

Functionally Pathogenic Ears2 Variants In Vitro May Not Manifest A Phenotype In Vivo, Nathan Mcneill, Alessia Nasca, Aurelio Reyes, Benjamin Lemoine, Brandi Cantarel, Adeline Vanderver, Raphael Schiffmann, Daniele Ghezzi

Neurology Faculty Publications

Objective: To investigate the genetic etiology of a patient diagnosed with leukoencephalopathy, brain calcifications, and cysts (LCC).

Methods: Whole-exome sequencing was performed on a patient with LCC and his unaffected family members. The variants were subject to in silico and in vitro functional testing to determine pathogenicity.

Results: Whole-exome sequencing uncovered compound heterozygous mutations in EARS2, c.328G>A (p.G110S), and c.1045G>A (p.E349K). This gene has previously been implicated in the autosomal recessive leukoencephalopathy with thalamus and brainstem involvement and high lactate (LTBL). The p.G110S mutation has been found in multiple patients with LTBL. In silico analysis supported pathogenicity …

An Enduring Legacy Of Discovery: Margaret Stirewalt., Lucie Henein, James J Cody, Michael H Hsieh

Urology Faculty Publications

No abstract provided.

Colonizing Opportunistic Pathogens (Cops): The Beasts In All Of Us., Lance B Price, Bruce A Hungate, Benjamin J Koch, Gregg S Davis, Cindy M Liu

Environmental and Occupational Health Faculty Publications

Colonizing opportunistic pathogens (COPs) are microbes that asymptomatically colonize the human body and, when the conditions are right, can cause infections. Their ability to persist indefinitely and to be transmitted without detection [1] gives COPs a unique epidemiology that warrants special consideration. There are examples of COPs among bacteria, fungi (e.g., Candida albicans [2]), protozoa (e.g., Blastocystis [3, 4]), and viruses (e.g., Rhinovirus [5]), but bacterial COPs are of particular relevance because of their major contribution to today’s antibiotic resistance crisis. The COPs include a long list of notorious bacteria that …

Colonizing Opportunistic Pathogens (Cops): The Beasts In All Of Us., Lance B Price, Bruce A Hungate, Benjamin J Koch, Gregg S Davis, Cindy M Liu

Environmental and Occupational Health Faculty Publications

Colonizing opportunistic pathogens (COPs) are microbes that asymptomatically colonize the human body and, when the conditions are right, can cause infections. Their ability to persist indefinitely and to be transmitted without detection [1] gives COPs a unique epidemiology that warrants special consideration. There are examples of COPs among bacteria, fungi (e.g., Candida albicans [2]), protozoa (e.g., Blastocystis [3, 4]), and viruses (e.g., Rhinovirus [5]), but bacterial COPs are of particular relevance because of their major contribution to today’s antibiotic resistance crisis. The COPs include a long list of notorious bacteria that …

Bibliography Of Physician Wellness Resources, Elizabeth C. Lawrence

Office of Physician and Student Wellness (OPSW)

Current list of articles and books on physician wellness.

Does Liberalizing State Nurse Practitioner Scope Of Practice Laws Affect The Primary Care Provider Composition And Productivity In Community Health Centers?, Jeongyoung Park, Xinxin Han, Ellen T. Kurtzman

Health Workforce Research Center Publications

The state scope of practice (SOP) laws determine the range of services nurse practitioners (NPs) can provide and the extent to which they can practice independently. This has been a hot topic amid concerns about primary care provider shortages in light of health reform coverage expansion. Many states consider liberalizing NP SOP laws in an effort to expand primary care capacity. As the demand for primary care increases, NPs are expected to have an active role in meeting primary care needs. The purpose of this study was to examine the effects of expanded nurse practitioner (NP) scope of practice (SOP) …

Proximal Femur Locking Plate For Sub-Trochanteric Femur Fractures: Factors Associated With Failure, Akbar Zubairi, Rizwan Haroon Rashid, Marij Zahid, Pervaiz Mahmood Hashmi, Shahryar Noordin

Section of Orthopaedic Surgery

Introduction: Proximal femur locking compression plates (PF-LCP) have gained popularity since their inception due to superior biomechanical stability and durability but clinical experience has shown conflicting results including implant failure.
Objective: To study the incidence of implant failure in patients with sub-trochanteric fractures managed with proximal femoral locking compression plate and identify potential risk factors associated with the failure.
Materials & Methods: Fifty patients with sub-trochanteric fractures, operated upon with titanium PF-LCP were included in the study from January 2012 to December 2014. These plates were of two designs including one five 5.0 mm proximal locking screws (implant A) and …

Peer Violence Perpetration And Victimization: Prevalence, Associated Factors And Pathways Among 1752 Sixth Grade Boys And Girls In Schools In Pakistan, Rozina Karmaliani Professor, Judith Mcfarlane, Rozina Somani, Hussain Maqbool Ahmed Khuwaja, Shireen Shehzad Bhamani, Tazeen Saeed Ali, Saleema A. Gulzar, Yasmeen Hassan Somani, Esnat D. Chirwa, Rachel Jewkes

School of Nursing & Midwifery

Background: Child peer violence is a global problem and seriously impacts health and education. There are few research studies available in Pakistan, or South Asia. We describe the prevalence of peer violence, associations, and pathways between socio-economic status, school performance, gender attitudes and violence at home.
Methods: 1752 children were recruited into a cluster randomized controlled trial conducted on 40 fairly homogeneous public schools (20 for girls and 20 for boys), in Hyderabad, Pakistan. This was ranging from 20-65 children per school. All children were interviewed with questionnaires at baseline.
Results: Few children had no experience of peer violence in …

Therapeutic Considerations For Antihyperglycemic Agents In Diabetic Kidney Disease., Joshua J Neumiller, Radica Alicic, Katherine Tuttle

Articles, Abstracts, and Reports

Diabetic kidney disease is among the most frequent complications of diabetes, with approximately 50% of patients with ESRD attributed to diabetes in developed countries. Although intensive glycemic management has been shown to delay the onset and progression of increased urinary albumin excretion and reduced GFR in patients with diabetes, conservative dose selection and adjustment of antihyperglycemic medications are necessary to balance glycemic control with safety. A growing body of literature is providing valuable insight into the cardiovascular and renal safety and efficacy of newer antihyperglycemic medications in the dipeptidyl peptidase-4 inhibitor, glucagon-like peptide-1 receptor agonist, and sodium-glucose cotransporter 2 inhibitor …

The Role Of Leader Empowering Behaviors On Work Engagement And Intent To Stay Among Staff Nurses In Acute Care Hospitals, Ingrid Kindipan

Nursing Dissertations - Archive

Leader empowering behavior is a facilitative process where employees perceive their leader to allow self-management and self-leadership of employees. Leader empowering behaviors can be perceived by employees as either enabling or burdensome. The purpose of this descriptive correlational study was to examine the relationship of leader empowering behaviors with nurse demographics, work engagement and intent to stay. A convenience sample of nurses (N = 212) employed in various nursing units within four hospitals completed an online survey related to perceived leader empowering behaviors, and the nurse’s level of work engagement and intent to stay in his/her organization of employment. Overall, …

Clinical And Experimental Studies Of A Novel P525r Fus Mutation In Amyotrophic Lateral Sclerosis, Lisha Kuang, Marisa Kamelgarn, Alexandra Arenas, Jozsef Gal, Deborah Taylor, Weiming Gong, Martin Brown, Daret St. Clair, Edward J. Kasarskis, Haining Zhu

Molecular and Cellular Biochemistry Faculty Publications

Objective: To describe the clinical features of a novel fused in sarcoma (FUS) mutation in a young adult female amyotrophic lateral sclerosis (ALS) patient with rapid progression of weakness and to experimentally validate the consequences of the P525R mutation in cellular neuronal models.

Methods: We conducted sequencing of genomic DNA from the index patient and her family members. Immunocytochemistry was performed in various cellular models to determine whether the newly identified P525R mutant FUS protein accumulated in cytoplasmic inclusions. Clinical features of the index patient were compared with 19 other patients with ALS carrying the P525L mutation in the same …

Activity Spotlight: Zika Prevention, Breakthrough Research

Poverty, Gender, and Youth

In collaboration with Breakthrough ACTION, an affiliated project led by the Johns Hopkins University Center for Communication Programs, Breakthrough RESEARCH is supporting and strengthening USAID’s Zika response efforts to optimize social and behavior change programming to minimize negative pregnancy outcomes in USAID’s priority countries in Latin America and the Caribbean. Breakthrough RESEARCH is leading an evidence review of commonly promoted Zika preventive behaviors and with Breakthrough ACTION will develop a process for prioritizing these behaviors using criteria considering efficacy, feasibility, and potential impact. A key outcome of this process will be an evidence-based list of priority prevention behaviors shared via …

Diabetes In Sub-Saharan Africa: From Clinical Care To Health Policy., Rifat Atun, Justine I. Davies, Edwin A.M. Gal, Till Bärnighausen, David Beran, Andre Pascal Kengne, Naomi S. Levitt, Florence Mangugu, Moffat J. Nyirenda, Graham D. Ogle, Kaushik Ramaiya

Paediatrics and Child Health, East Africa

Rapid demographic, sociocultural, and economic transitions are driving increases in the risk and prevalence of diabetes and other non-communicable diseases (NCDs) in sub-Saharan Africa. The impacts of these transitions and their health and economic consequences are evident. Whereas, in 1990, the leading causes of death in sub-Saharan Africa were HIV/AIDS, lower respiratory infections, diarrhoeal diseases, malaria, and vaccine-preventable diseases in children, in more recent years, cardiovascular diseases and their risk factors are replacing infectious diseases as the leading causes of death in this region, and rates of increase of cardiovascular risk factors are predicted to be greater in sub-Saharan Africa …

Elongation Factor P Interactions With The Ribosome Are Independent Of Pausing, Rodney Tollerson Ii, Anne Witzky, Michael Ibba

Biology, Chemistry, and Environmental Sciences Faculty Articles and Research

Bacterial elongation factor P (EF-P) plays a pivotal role in the translation of polyproline motifs. To stimulate peptide bond formation, EF-P must enter the ribosome via an empty E-site. Using fluorescence-based single-molecule tracking, Mohapatra et al. (S. Mohapatra, H. Choi, X. Ge, S. Sanyal, and J. C. Weisshaar, mBio 8:e00300-17, 2017, https://doi.org/10.1128/mBio.00300-17 ) monitored the cellular distribution of EF-P and quantified the frequency of association between EF-P and the ribosome under various conditions. Findings from the study showed that EF-P has a localization pattern that is strikingly similar to that of ribosomes. Intriguingly, EF-P was seen to bind ribosomes more …

Incidence, Positional Distribution, Severity, And Time Missed In Medial Collateral Ligament Injuries Of The Knee In Ncaa Division I Football Athletes., Ali R Motamedi, Anirudh K Gowd, Alireza K Nazemi, Stephen T Gardner, Caleb J Behrend

Articles, Abstracts, and Reports

Introduction: We studied injury to the medial collateral ligament (MCL) in National Collegiate Athletic Association (NCAA) Division I football players, their incidence, magnitude of injury, distribution by position, and missed time, which has not previously been described in a consecutive series.

Methods: The knee injuries sustained in 163 consecutive NCAA Division I collegiate football players at our institution were evaluated over a span of 6 years.

Results: The incidence of MCL injuries with any knee injury was 29% (47 of 163). Of 47 MCL injuries, 34% occurred in defensive linemen and 29% in offensive linemen. The average days missed by …

Sphingolipids In Models Of Kidney Disease And Injury., Tess V. Dupre

Electronic Theses and Dissertations

Acute kidney injury (AKI), resulting from cisplatin, remains an obstacle in the treatment of cancer. Cisplatin-induced AKI involves cell death pathways regulated by sphingolipids such as ceramide and glucosylceramide. Results indicate that cisplatin-treated mice had increased levels of ceramide and hexosylceramide. Pre-treatment of mice with inhibitors of ceramide synthesis prevented accumulation of ceramide and hexosylceramide in the renal cortex and attenuated cisplatin-induced AKI. To determine the role of ceramide metabolism to hexosylceramides in kidney injury, we treated mice with an inhibitor of glycosphingolipid synthesis. Inhibition of glycosphingolipid synthesis attenuated the accumulation of the hexosylceramide and exacerbated ceramide accumulation in the …

Exploring Men's Motivations And Restraints In Repeated Extramarital Sex, Casey Marie Stinley

Graduate Theses/Dissertations

The influence of extramarital sex (EMS) on marriage has been a topic of discussion in the research community for over 30 years. This thesis explored the influences that drive the EMS participants’ decisions, whether to abstain, continue while in the marriage, or to leave the marriage, and, those influences that affect whether they later participate in EMS or not. This study also used individual semi-structured interviews of ex-husbands who have participated in EMS in the past, as well as husbands who are participating in EMS currently. The four men interviewed were from southwest Missouri. The interviews were reviewed to identify …

Ablation Of Adipose-Ho-1 Expression Increases White Fat Over Beige Fat Through Inhibition Of Mitochondrial Fusion And Of Pgc1alpha In Female Mice, S Singh, I Grant, A Meissner, A Kappas, Nader Abraham

NYMC Faculty Publications

Background Hmox1 plays an important role in the regulation of mitochondrial bioenergetics and function by regulating cellular heme-derived CO and bilirubin. Previous studies have demonstrated that global disruption of HO-1 in humans and mice resulted in severe organ dysfunction. Methods We investigated the potential role of adipose-specific-HO-1 genetic ablation on adipose tissue function, mitochondrial quality control and energy expenditure by generating an adipo-HO-1 knockout mouse model (Adipo-HO-1-/-) and, in vitro, adipocyte cells in which HO activity was inhibited. Adiposity, signaling proteins, fasting glucose and oxygen consumption were determined and compared to adipocyte cultures with depressed levels of both HO-1/HO-2. Results …

Mindfulness-Based Stress Reduction In Women With Overweight Or Obesity: A Randomized Clinical Trial., Nazia Raja-Khan, Katrina Agito, Julie Shah, Christy M Stetter, Theresa S Gustafson, Holly Socolow, Allen R Kunselman, Diane K. Reibel, Richard S Legro

Marcus Institute of Integrative Health Faculty Papers

OBJECTIVE: To evaluate the feasibility and cardiometabolic effects of mindfulness-based stress reduction (MBSR) in women with overweight or obesity.

METHODS: Eighty-six women with BMI ≥ 25 kg/m

RESULTS: Compared to health education, the MBSR group demonstrated significantly improved mindfulness at 8 weeks (mean change from baseline, 4.5 vs. -1.0; P = 0.03) and significantly decreased perceived stress at 16 weeks (-3.6 vs. -1.3, P = 0.01). In the MBSR group, there were significant reductions in fasting glucose at 8 weeks (-8.9 mg/dL, P = 0.02) and at 16 weeks (-9.3 mg/dL, P = 0.02) compared to baseline. Fasting glucose did …

Substance Use Disorders, Violence, Mental Health, And Hiv: Differentiating A Syndemic Factor By Gender And Sexuality, Kiyomi Tsuyuki, Eileen V. Pitpitan, Maria A. Levi-Minzi, Lianne A. Urada, Steven P. Kurtz, Jamila K. Stockman, Hilary L. Surratt

Center for Health Services Research Faculty Publications

This paper measures syndemic substance use disorder, violence, and mental health and compares the syndemic among HIV-infected heterosexual men, heterosexual women, and men who have sex with men (MSM). Data were from a sample of high needs substance-using, HIV-infected people in South Florida between 2010 and 2012 (n = 481). We used confirmatory factor analysis to measure a syndemic latent variable and applied measurement invariance models to identify group differences in the data structure of syndemic co-morbidities among heterosexual men, heterosexual women, and MSM. We found that variables used to measure the syndemic fit each sub-group, supporting that substance use …

Brain Microvascular Injury And White Matter Disease Provoked By Diabetes-Associated Hyperamylinemia, Han Ly, Nirmal Verma, Fengen Wu, Miao Liu, Kathryn E. Saatman, Peter T. Nelson, John T. Slevin, Larry B. Goldstein, Geert Jan Biessels, Florin Despa

Pharmacology and Nutritional Sciences Faculty Publications

OBJECTIVE: The brain blood vessels of patients with type 2 diabetes and dementia have deposition of amylin, an amyloidogenic hormone cosecreted with insulin. It is not known whether vascular amylin deposition is a consequence or a trigger of vascular injury. We tested the hypothesis that the vascular amylin deposits cause endothelial dysfunction and microvascular injury and are modulated by amylin transport in the brain via plasma apolipoproteins.

METHODS: Rats overexpressing amyloidogenic (human) amylin in the pancreas (HIP rats) and amylin knockout (AKO) rats intravenously infused with aggregated amylin were used for in vivo phenotyping. We also carried out biochemical analyses …

A Retrospective Review Of Paediatric Head Injuries In Asia - A Pan Asian Trauma Outcomes Study (Patos) Collaboration, Shu-Ling Chong, Uzma R. Khan, Indumathy Santhanam, Jun Seok Seo, Quan Wang, Sabariah Faizah Jamaluddin,, Quoc Ai Hoang Quoc, Su Yah Chew, Marcus Eng Hock Ong

Department of Emergency Medicine

Objective: We aim to examine the mechanisms of head-injured children presenting to participating centres in the Pan Asian Trauma Outcomes Study (PATOS) and to evaluate the association between mechanism of injury and severe outcomes.
Design and Setting: We performed a retrospective review of medical records among emergency departments (EDs) of eight PATOS centres, from September 2014 - August 2015.
Participants: We included children <16 years old who presented within 24 hours of head injury and were admitted for observation or required a computed tomography (CT) of the brain from the ED. We excluded children with known coagulopathies, neurological co-morbidities or prior neurosurgery. We reviewed the mechanism, intent, location and object involved in each injury, and the patients' physical findings on presentation.
Outcomes: Primary outcomes were death, endotracheal intubation or neurosurgical intervention. Secondary outcomes included hospital and ED length of stay.
Results: 1438 children were analysed. 953 children (66.3%) were male and the median age was 5.0 years (IQR …

High Agreement Between Benchtop And Point-Of-Care Dipcard Tests For Ethyl Glucuronide., Emily Leickly, Jordan Skalisky, Sterling Mcpherson, Michael F Orr, Michael G Mcdonell

Articles, Abstracts, and Reports

No abstract provided.

Long Working Hours And Occupational Stress-Related Illness And Injury: Mini Review, Harrynauth Persaud, Shawn Williams

Publications and Research

Workplace injuries and illnesses have been associated with long working hours. In the United States, working overtime has been on the rise. It is estimated that American workers spend an extra 1.5 hours per week at their job, and for those working in manufacturing-overtime has increased by 25% when compared to 10 years ago. Data suggests that working greater than 12 hours in a single day was associated with a 37% (95% CI=1.16–1.59) increase in hazard rate (HR), while working greater than 60 hour per week was associated with a 23% (95% CI=1.05–1.45) increase in HR. For those working overtime, …